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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602017
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:52:31 PM

Document Has Been Signed on 10/17/2024 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PALACIOS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198602017
ADMINISTRATOR/
DIRECTOR:		PALACIOS, RAQUELFACILITY TYPE:
735
ADDRESS:1232 MILLBURY AVETELEPHONE:
(626) 338-0854
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 6CENSUS: 5DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:36 PM
MET WITH:Administrator Raquel PalaciosTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 10/17/2024 and was greeted by Administrator Raquel Palacios and explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to clients, were observed to be inaccessible to clients. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) client rooms. All client bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C).

Client Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice.

See 809-C.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PALACIOS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198602017
VISIT DATE: 10/17/2024
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Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Last documented emergency drills were conducted on 04/04/2024 & 12/14/2023. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply.

Health Related Services: The medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Raquel Palacios expires 05/20/2024. LPA Ramirez verified Administrator Palacios’ certificate is currently being processed for renewal. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel records reviewed.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for six (6) ambulatory of which three (3) may be non-ambulatory.

Client Records/Incident Reports: LPA reviewed client files for five (5) clients. Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights and Individual Personal Plan (IPP) were observed. LPA Ramirez observed C2 walking into the facility wearing a helmet. During record review, LPA Ramirez did not observe exception granted for use of protective devices for C2. LPA Ramirez will issue Technical Violation. Administrator Palacio’s agreed to send request for exception by 11/07/2024.

No deficiencies were cited during this inspection. Exit interview was conducted. A copy of this report, LIC 9102 and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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